Facts about abortions.
The experience of patients admitted to a general hospital with a diagnosis of acute pulmonary oedema for the year before and after the opening of an intensive care unit is reviewed, with findings that an increase in the number of investigations and the com-i plexity of treatment does not lead automatically to a better outcome.
Abstract
the blood is achieved. However, in severe cases of pulmonary oedema flow rates of 20 l./min may be insufficient, so that severe and progressive respiratory acidosis develops. In such cases intermittent positive-pressure ventilation,' and in the most extreme cases continuous positive-pressure ventilation,6 have been suggested. Rotaiting tourniquets may be used to produce a temporary reduction in ventricular filling pressure. The acute form of pulmonary oedema is a medical emergency and presents a striking clinical picture. Laboratory measurements of respiratory and cardiac function and blood gas tensions may show gross abnormalities. It is not surprising that the improved understanding of its pathophysiology and the recognition that non-cardiac percipiating factors are increasingly important has led to a policy in some centres to admit patients with acute pulmonary oedema to intensive care units for immediate and close surveillance. Whether admission to such units is the best policy is still debated. P. F. Griner7 has reviewed the experience of aduJtt patients admitted to a general hospital with a diagnosis of acute pulmonary oedema for the year before and after the opening of an intensive care unit. In both years the numbers of patients and their characteristics were broadly similar. Few patients had evidence of acute myocardial infarction (13%). After the opening of the intensive care unit 50% of the cases of acute pulmonary oedema which were referred were able to be accommodated. However, the mortality rate for acute pulmonary oedema was unchanged (8%), the duration of stay in hospital was longer, and the number of intuibations doubled and was considered to be excessive at 40%. The number of blood gas measurements was five times greater than in those patients with acute pulmonary oedema treated in the general medical units. Though the patients were in the intensive care unit for only 26% of their hospital stay, the bills were 82% greater (average $3,448) than for those treated in the general medical wards ($1,893). Griner comments that the most noticeable change after the opening of the new unit was the increase in the cost of treatment, though he notes that other important factors such as patient comfort and satisfaction were not compared. In the hospital under study these findings have led to a re-evaluation of the policy for the admission of patients with acute pulmonary oedema. After appropriate treatment in the emergency rooms, only exceptionally rn patients with acute pulmonary oedema are now admitted to the intensive care unit. Despite the difficulty of making exact comparisons in such cases, Griner's findings are a salutary reminder that an increase in the number of investigations and the com-i plexity of treatment does not lead automatically to a better outcome. The easy access to hospital under the Health Service in Great Britain, without direct cost at the time, should not be allowed to reduce the clear responsibility of doctors to evaluate at regular intervals the detailed management of different conditions.